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LEARNING OBJECTIVES
After reviewing this module, the student will have the
ability to:

- Approach History & physical exam of patients with

thyroid pathology
- Understand which patients require surgery and
appropriate surgical timing
- Describe the process of evaluating and working up
various thyroid pathologies
CASE PRESENTATION
29 year old Female referred to Head & Neck clinic for
evaluation of a thyroid nodule. Patient reports this
nodule was found incidentally while she was getting
ready for work one morning.
She went to her PCP, who ordered a thyroid ultrasound,
which demonstrated a 2cm nodule in the right lobe of
the thyroid.
QUESTION
After thorough history and physical, what would
you order first for this patient?

 A. Thyroid function tests (TSH, T4)

 B. CT neck
 C. MRI neck
 D. Radioactive Iodine uptake scan
 E. All of the above
QUESTION
After thorough history and physical, what would
you order first for this patient?

 A. Thyroid function tests (TSH, T4)

 B. CT neck
 C. MRI neck
 D. Radioactive Iodine uptake scan
 E. All of the above
EXPLANATION
What would you order first for this patient?
 A. Thyroid function tests (TSH, T4)

It is important to first establish the patient’s thyroid

function. This will help determine if the known thyroid
nodule is hyperfunctioning, hypofunctioning, or
nonfunctioning.

At this point, you should also obtain Fine Needle

Aspiration (FNA) with ultrasound guidance, if necessary,
to obtain cells for cytopathology. This will help
determine if nodule is benign or malignant
IMPORTANT POINTS - PATIENT HISTORY
Family history of thyroid disease or thyroid
cancer?
 Familial syndromes (MEN)
Personal history of radiation to head/neck
 Increased risk of thyroid cancer
Hoarseness, SOB, difficulty swallowing
 Compressive symptoms of thyroid goiter
CASE PRESENTATION
Patient reports her voice seems to have become slightly
more “husky” lately. She recalls only occasional
discomfort with sensation that something is “pushing”
in. Denies shortness of breath.

Denies family history of thyroid cancer

Denies personal history of radiation therapy or thyroid or

any other type of cancer
PHYSICAL EXAM
What components of the physical exam are critical
for this patient?

 Full Head and neck exam to look for any “lumps or bumps”

 Palpate for lymphadenopathy

 Palpate thyroid for nodularity, firmness or hard masses

 Fiberoptic or direct laryngoscopy to evaluate vocal cord

function
CASE PRESENTATION
On physical exam, you palpate a grossly enlarged thyroid gland
with a 1.5cm dominant nodule on the right thyroid lobe
You discover the following findings on fiberoptic exam:

View on laryngoscopy
Upon inspiration: Opening of esophagus

Symmetric bilateral
Vocal fold abduction
trachea
Vocal folds
(true cords)

Epiglottis

False vocal folds

Base of tongue/lingual tonsil

anterior
QUESTION
Patient is sent for labs as well as FNA. Patient
returns to clinic the following week with FNA
report reading “follicular cells, cannot rule out
follicular neoplasm”. Is surgery indicated for
your patient at this time?

 Yes
 No
QUESTION
Patient is sent for labs as well as FNA. Patient
returns to clinic the following week with FNA
report reading “follicular cells, cannot rule out
follicular neoplasm”. Is surgery indicated for
your patient at this time?

 Yes
 No
EXPLANATION
Surgery is indicated. Follicular cells on FNA can be a
benign finding or may indicate follicular carcinoma.
 Follicular carcinoma cannot be diagnosed solely on FNA
(normal thyroid contains follicular cells.)
 Perform at least hemithyroidectomy for tissue diagnosis

 Tissue taken at time of surgery must be sent for pathology

to evaluate for extracapsular extension, lymphovascular
invasion, or metastasis.

 Therefore, in the case that follicular neoplasm is suspected

based on H&P and FNA results, patient should be taken to
surgery for pathologic diagnosis and treatment.
INDICATIONS FOR THYROIDECTOMY
- Hyperthyroidism (Grave’s) not
responsive to medical therapy with
ophthalmic symptoms
- Malignancy (confirmed or high
suspicion based on history and/or
FNA)
- Goiter with compressive symptoms
- Large thyroid nodule (>2cm) that is
unable to be adequately sampled by
FNA (sampling error due to large
area of nodule and risk of
combination of benign and
malignant cells)
ETIOLOGIES OF THYROID NODULES

Benign Malignant
 Benign thyroid  Papillary carcinoma
cysts  Follicular carcinoma
(degenerated  Hurthle cell tumor
nodules)  Medullary Thyroid
 Colloid nodules Carcinoma
 Anaplastic
 Multinodular
Carcinoma
goiter  Lymphoma of
thyroid
TESTS
- CBC, Chemistry
 Chemistry for calcium, to include albumin to calculate
corrected calcium
 Corrected Ca = 0.8 x (4 - patient albumin) + pt Ca
- Thyroid function (TSH, free T4)
- Parathyroid hormone (PTH)
- Coagulation studies (INR, PTT)
- FNA of nodule (+/- Ultrasound guidance)
- CT Neck for surgical planning, if
appropriate
 IMAGING

- Ultrasound
- CT Neck for surgical
planning

CT scan demonstrating large Right thyroid

mass causing tracheal deviation to left
THYROID ULTRASOUND

Normal thyroid and surrounding neck anatomy

 TREATMENT

Medical Management
 Involve endocrinology early to assist in management
 Thyroid hormone replacement (Levothyroxine) for
hypothyroidism
 Thyroid suppression for hyperthyroidism
 I-131 for medical thyroid ablation
 Observation for benign nodules
Surgery
 Failure of medical management
 Malignancy or concern for malignant potential
 Symptom management
TREATMENT
- Post-surgical therapy
 I-131 : Radioactive iodine ablation may be indicated
postoperatively for any residual malignancy
 Thyroid hormone replacement after total
thyroidectomy
 Calcium replacement
 Surgery to thyroid/parathyroid bed

- Ensure patient has endocrinology follow up

 Titrate levothyroxine and help manage long term
iatrogenic hypothyroidism
ALGORITHM/OVERVIEW
Thyroid nodule/mass

Repe
at F NA

Follow
clinicall Tissue
y pathology
COMPLICATIONS OF THYROIDECTOMY
- Intraoperative
- Bleeding
- Damage to arteries/veins of neck
If patient develops expanding
- Postoperative presentation neck hematoma
postoperatively, treatment
- Injury to recurrent laryngeal nerve involves immediate opening of
- Unilateral: hoarseness sutures to evacuate clot and
return to OR to explore and
- Bilateral: respiratory distress stop bleed
- Bleeding
- Expanding hematoma – causes compression, shortness of breath
- Hypocalcemia
- Removal or injury to parathyroid glands or their blood supply
- Scar
TAKE HOME POINTS
- Always obtain thyroid function tests as
part of intial workup in patient with
thyroid pathology

- Perform full Head & Neck exam

- Thyroid nodules should undergo FNA for

cytopathology results
 RESOURCES
Flint. Cummings Otolaryngology: Head & Neck Surgery, 5th
ed. 2010 Mosby/Elsevier.
Kwak, et al. Findings of Extrathyroid Lesions Encountered
With Thyroid Sonography. J Ultrasound Med 2007; 26:1747–
1759
Netter Atlas of Anatomy – Accessed via The Netter presenter :
human anatomy collection. edited by John T. Hansen.
Elsevier 2010.
Pasha, Raza. Otolaryngology Head & Neck Surgery: Clinical
Reference Guide. 3rd edition
Shahi et al. Journal of Medical Case Reports 2010 4:15
doi:10.1186/1752-1947-4-15
Photo credit: UT Voice Center Website
http://uthscsa.edu/oto/voicecenterhome.asp
 ACKNOWLEDGEMENTS
Thank you to Christian Stallworth, MD for overseeing this
project and providing advisory support.

Photo credits- Thank you to Megan M. Gaffey, MD and

Lauren Thomas for providing photos of the physical
exam

Editing and input: